Case Manager, TCM & Avivo Village

Do you know, you have the power to change the course of someone’s life? Avivo employees do this every day, and we want you to join the team. At Avivo, our employees work with utter commitment to their clients, embracing the full person, believing in the dignity of all people.

The Targeted Case Manager will provide Targeted Case Management services to adults with mental illness, to assist them to live successfully in their goal living situation. This is accomplished by connecting participants to necessary support services, coordinating with other care providers, gathering resources, and assisting with applications and renewals when necessary. This position also assists adults with serious mental illness in pursuing the outcome of improved or maintained mental health functioning.

Avivo Village is an alternative to encampments that provides a safe, secure, and service-rich environment for individuals experiencing unsheltered homelessness as they work toward long-term housing stability. The embedded Targeted Case Manager will engage eligible residents, complete assessments and service planning, coordinate access to behavioral health, medical, housing, benefits, and community-based resources, and provide ongoing support toward individualized goals. The Targeted Case Manager will work closely with Avivo Village staff, the embedded mental health clinician, housing case managers, and other service partners to ensure coordinated, person-centered care. The position will also receive ongoing support, consultation, and oversight from the TCM Program Director, supervisors, and program managers.

PRIMARY RESPONSIBILITIES:

• Build meaningful, person-centered relationships with residents while maintaining appropriate professional boundaries.

• Maintain a consistent and visible presence within Avivo Village to provide accessible, low-barrier Targeted Case Management services.

• Proactively engage residents through flexible and creative outreach strategies, including residents who may be hesitant or have difficulty participating in traditional office-based services.

• In collaboration with TCM leadership, assess residents’ eligibility for Adult Mental Health Targeted Case Management and other programs and services, educate residents and staff about eligibility requirements, and support enrollment when appropriate.

• Collaborate with residents to develop, implement, and regularly update the Individual Community Support Plan. Ensure that services provided and changes in client goals are accurately reflected in the plan.

• Make appropriate internal and external referrals, monitor progress, and ensure timely follow-up and continuity of services.

• Meet with each client on the assigned caseload at least monthly and complete timely, accurate, and billable case documentation in accordance with TCM requirements.

• Coordinate care with Avivo Village staff, the embedded mental health clinician, housing case managers, TCM program leadership, medical and behavioral health providers, and other community partners.